Pre‐operative fasting in adults and children: clinical practice and guidelines

Abstract

Summary It is widely recognised that prolonged fasting for elective surgery in both children and adults serves no purpose, adversely affects patient well‐being and can be detrimental. Although advised fasting times for solids remain unchanged, there is good evidence to support a 1‐h fast for children, with no increase in risk of pulmonary aspiration. In adults, a major focus has been the introduction of carbohydrate loading before anaesthesia, so that patients arrive for surgery not only hydrated but also in a more normal metabolic state. The latter attenuates some of the physiological responses to surgery, such as insulin resistance. As in children, there is no increase in risk of pulmonary aspiration. Further data are required to guide best practice in patients with diabetes.

Doubt about pre‐operative carbohydrate supplementation

“…In reply to Desgranges et al [1], although some may argue that chewing gum does not technically constitute food or drink, we agree this is very relevant to the whole concept of pre-operative fasting.…”

“…We wish to mount further direct challenges to the concept of preCHO, on several grounds. The subjective benefits of preCHO, namely the reduction in anxiety, distress, thirst and hunger [1][2][3], are relative to the dietary habit of the subject during the preceding weeks, as much as they are to the immediate duration of…”

“…As water is also ingested until 2 h before surgery, a Mounting evidence supports gum chewing preoperatively without added risk to paediatric or adult patients [5], and we support this. However, it may take some time for this to be reflected in other guidelines; for example, We are also grateful for the kind interest shown in our article by Scott et al [1]. We did not intend to suggest that the pathophysiology of major surgery and high performance athletes were similar, except that both groups have carbohydrate loading in common, and that lactic acid accumulation is disadvantageous to both.…”

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Doubt about pre-operative carbohydrate supplementationWe commend Fawcett and Thomas for their review of pre-operative fasting recommendations [1] and applaud their candid acknowledgement of the mounting evidence of lack of clinical benefit for oral pre-operative carbohydrate loading (preCHO), considered an essential element of the enhanced recovery after surgery (ERAS) programme [2].We wish to mount further direct challenges to the concept of preCHO, on several grounds. The subjective benefits of preCHO, namely the reduction in anxiety, distress, thirst and hunger [1][2][3], are relative to the dietary habit of the subject during the preceding weeks, as much as they are to the immediate duration of

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“…A predominantly carbohydrate-based 'standard' diet (such as has been advised by national advisory bodies for several decades) accentuates these symptoms, whereas the widespread adoption of reduced fasting times for both food and water (6 h and 2 h, respectively), reduces the impact of this acute deprivation. Indeed, preCHO has been shown to be of benefit only when compared with fasting without water, but negligible when compared with water [1]. The analogy drawn between surgical stress and exercise, with respect to lactate production and carbohydrate loading, is both false and out-dated.…”